Clinical Review Martin P Nevitt M.D., M.P.H NDA 22-134 (b) (4) (alcaftadine ophthalmic solution) 0.25% CLINICAL REVIEW Application Type NDA Application Number(s) 22-134 Priority or Standard S Submit Date(s) September 29, 2009 Received Date(s) September 29, 2009 PDUFA Goal Date July 28, 2010 Division / Office DAIOP Reviewer Name(s) Martin P. Nevitt, M.D.,M.P.H. Review Completion Date April 2, 2010 Established Name alcaftadine ophthalmic solution, 0.25% (Proposed) Trade Name Lastacaft Therapeutic Class histamine H1 receptor antagonist Applicant Vistakon Pharmaceuticals, LLC Formulation(s) Topical ophthalmic Dosing Regimen One drop each eye daily Indication(s) Prevention of itching associated with allergic conjunctivitis Intended Population(s) Patients ≥ 2 years old 1 Clinical Review Martin P Nevitt M.D., M.P.H NDA 22-134 (b) (4) (alcaftadine ophthalmic solution) 0.25% Table of Contents 1 RECOMMENDATIONS/RISK BENEFIT ASSESSMENT......................................... 5 1.1 Recommendation on Regulatory Action ............................................................. 5 1.2 Risk Benefit Assessment.................................................................................... 5 1.3 Recommendations for Postmarket Risk Evaluation and Mitigation Strategies ... 5 1.4 Recommendations for Postmarket Requirements and Commitments ................ 5 2 INTRODUCTION AND REGULATORY BACKGROUND ........................................ 5 2.1 Product Information ............................................................................................ 5 2.2 Tables of Currently Available Treatments for Proposed Indications ................... 6 2.3 Availability of Proposed Active Ingredient in the United States .......................... 6 2.4 Important Safety Issues With Consideration to Related Drugs........................... 6 2.5 Summary of Presubmission Regulatory Activity Related to Submission ............ 7 2.6 Other Relevant Background Information ............................................................ 7 3 ETHICS AND GOOD CLINICAL PRACTICES......................................................... 8 3.1 Submission Quality and Integrity ........................................................................ 8 3.2 Compliance with Good Clinical Practices ........................................................... 8 3.3 Financial Disclosures.......................................................................................... 9 4 SIGNIFICANT EFFICACY/SAFETY ISSUES RELATED TO OTHER REVIEW DISCIPLINES ........................................................................................................... 9 4.1 Chemistry Manufacturing and Controls .............................................................. 9 4.2 Clinical Microbiology........................................................................................... 9 4.3 Preclinical Pharmacology/Toxicology ................................................................. 9 4.4 Clinical Pharmacology...................................................................................... 10 4.4.1 Mechanism of Action.................................................................................. 10 4.4.2 Pharmacodynamics.................................................................................... 10 4.4.3 Pharmacokinetics....................................................................................... 10 5 SOURCES OF CLINICAL DATA............................................................................ 10 5.1 Tables of Studies/Clinical Trials ....................................................................... 10 5.2 Review Strategy ............................................................................................... 11 5.3 Discussion of Individual Studies/Clinical Trials................................................. 11 6 REVIEW OF EFFICACY......................................................................................... 21 Efficacy Summary...................................................................................................... 21 6.1 Indication .......................................................................................................... 21 6.1.1 Methods ..................................................................................................... 21 6.1.2 Demographics............................................................................................ 22 6.1.3 Subject Disposition .................................................................................... 22 6.1.4 Analysis of Primary Endpoint(s) ................................................................. 23 6.1.5 Analysis of Secondary Endpoints(s)........................................................... 25 2 Clinical Review Martin P Nevitt M.D., M.P.H NDA 22-134 (b) (4) (alcaftadine ophthalmic solution) 0.25% 6.1.6 Other Endpoints ......................................................................................... 26 6.1.7 Subpopulations .......................................................................................... 26 6.1.8 Analysis of Clinical Information Relevant to Dosing Recommendations .... 26 6.1.9 Discussion of Persistence of Efficacy and/or Tolerance Effects................. 26 6.1.10 Additional Efficacy Issues/Analyses........................................................... 26 7 REVIEW OF SAFETY............................................................................................. 28 Safety Summary ........................................................................................................ 28 7.1 Methods............................................................................................................ 28 7.1.1 Studies/Clinical Trials Used to Evaluate Safety ......................................... 28 7.1.2 Categorization of Adverse Events.............................................................. 28 7.1.3 Pooling of Data Across Studies/Clinical Trials to Estimate and Compare Incidence.................................................................................................... 28 7.2 Adequacy of Safety Assessments .................................................................... 28 7.2.1 Overall Exposure at Appropriate Doses/Durations and Demographics of Target Populations..................................................................................... 28 7.2.2 Explorations for Dose Response................................................................ 30 7.2.3 Special Animal and/or In Vitro Testing ....................................................... 30 7.2.4 Routine Clinical Testing ............................................................................. 30 7.2.5 Metabolic, Clearance, and Interaction Workup .......................................... 30 7.2.6 Evaluation for Potential Adverse Events for Similar Drugs in Drug Class .. 30 7.3 Major Safety Results ........................................................................................ 30 7.3.1 Deaths........................................................................................................ 30 7.3.2 Nonfatal Serious Adverse Events .............................................................. 30 7.3.3 Dropouts and/or Discontinuations .............................................................. 31 7.3.4 Significant Adverse Events ........................................................................ 34 7.3.5 Submission Specific Primary Safety Concerns .......................................... 34 7.4 Supportive Safety Results ................................................................................ 34 7.4.1 Common Adverse Events .......................................................................... 34 7.4.2 Laboratory Findings ................................................................................... 36 7.4.3 Vital Signs.................................................................................................. 36 7.4.4 Electrocardiograms (ECGs) ....................................................................... 36 7.4.5 Special Safety Studies/Clinical Trials......................................................... 36 7.4.6 Immunogenicity.......................................................................................... 37 7.5 Other Safety Explorations................................................................................. 37 7.5.1 Dose Dependency for Adverse Events ...................................................... 37 7.5.2 Time Dependency for Adverse Events....................................................... 37 7.5.3 Drug-Demographic Interactions ................................................................. 37 7.5.4 Drug-Disease Interactions.......................................................................... 37 7.5.5 Drug-Drug Interactions............................................................................... 37 7.6 Additional Safety Evaluations ........................................................................... 38 7.6.1 Human Carcinogenicity.............................................................................. 38 7.6.2 Human Reproduction and Pregnancy Data................................................ 38 7.6.3 Pediatrics and Assessment of Effects on Growth ...................................... 38 3 Clinical Review Martin P Nevitt M.D., M.P.H NDA 22-134 (b) (4) (alcaftadine ophthalmic solution) 0.25% 7.6.4 Overdose, Drug Abuse Potential, Withdrawal and Rebound.....................